Prior Authorization &
Coverage Decisions
Elderplan requires prior authorization (PA) — advance approval — for certain medical services before they are delivered. This guide covers what needs approval, how to request it, and your rights if a request is denied.
What would you like to do?
Understand Prior Authorization
Learn what PA is, why it exists, and how the process works
See What Requires Approval
Browse services requiring PA by plan type or category
Request Prior Authorization
Phone, online portal, fax — and electronic submission through your doctor's system coming in 2027
Decision Timeframes
Regulatory deadlines for standard and urgent reviews
Denied? Know Your Rights
How to appeal and what happens at each level
Check Authorization Status
Track the status of a pending or past request
Our 2025 Prior Authorization Results
In compliance with the federal interoperability rules, Elderplan publicly reports prior authorization outcome metrics annually. The 2025 metrics are now posted.
What is Prior Authorization?
Prior authorization (PA) — sometimes called pre-approval — is a process where Elderplan reviews whether a proposed medical service meets coverage criteria before it is delivered.
The Prior Authorization Process
Your doctor orders a service
Your physician or specialist determines that a particular treatment, procedure, equipment, or facility stay is medically necessary for your care.
Check whether PA is required
Not every service requires prior authorization. Use the Services Requiring PA section to confirm whether your specific service needs advance approval. Emergency and urgently needed services never require prior authorization.
Request is submitted
You, your representative, or your doctor submits a prior authorization request to Elderplan's care review team. Requests can be submitted by phone, online portal, or fax.
Elderplan reviews the request
Our clinical team reviews your request using Medicare's coverage guidelines. When Medicare doesn't have specific guidelines for a service, we use a nationally recognized clinical review tool to make sure decisions are based on medical evidence. No request is denied for medical necessity without a physician's review.
You receive a decision
Elderplan must issue a decision within 7 calendar days for standard requests, or 72 hours for expedited (urgent) requests. You will receive written notice of the decision — including a specific reason if the request is denied.
If denied — appeal
You have the right to appeal any denial. Elderplan provides a multi-level internal appeal process, followed by access to an independent external reviewer and Medicare escalation pathways.
The Purpose of Prior Authorization
Prior authorization serves several functions: it ensures that services are medically necessary and appropriate for your condition, prevents duplication of care, promotes use of evidence-based treatments, and coordinates care across multiple providers. At Elderplan, our goal is to ensure you get the right care at the right time — and PA is one of the tools we use to protect that standard.
Services Requiring Prior Authorization
The following categories of services require prior authorization before you receive them. Requirements vary by plan. Use the filter to see what applies to your specific plan.
How to Request Prior Authorization
Prior authorization requests may be submitted by you, your authorized representative, or your provider on your behalf. Choose the method that works best for you or your care team.
How to Submit a PA Request
By Phone
Call us to request prior authorization over the phone. We can also answer any questions about the process.
Elderplan Member Services at 1-800-353-3765 [TTY: 711], 8 a.m. to 8 p.m., seven days a week
By Fax
Submit a written PA request form by fax. Include the member ID, diagnosis, relevant clinical documentation, and the requested service.
718-759-5240Electronic Submission Through Your Doctor's System (Coming 2027)
A new federal rule requires health plans to support electronic prior authorization submission through
certified health record systems starting January 1, 2027. This means your doctor's office will be able
to submit requests directly through their electronic records system.
Details available January 1, 2027
Information Required for Your Request
Member Information
Member full name, date of birth, and Elderplan Member ID number
Provider Information
Your doctor's name and contact information
Clinical Information
Diagnosis code(s), description of the requested service, and supporting clinical notes
Service Details
HCPCS or CPT code(s), proposed service dates, and setting (inpatient, outpatient, home)
Prior Authorization Decision Timelines
Federal regulations set maximum timeframes within which Elderplan must issue prior authorization decisions. These are your legal rights — not targets or goals.
Standard Prior Authorization
From the date Elderplan receives a complete PA request with sufficient clinical information. Applies to all non-urgent requests.
Expedited (Urgent) Review
For urgent requests where applying the standard timeframe could seriously jeopardize your life, health, or ability to regain maximum function.
When Does the Timeline Start?
The clock starts when we receive your complete request — including any medical records or clinical notes your doctor provides. If we need more information, we'll contact your provider right away. If we don't receive it in time, your review may take longer — but we'll always let you know.
What Happens if the Timeframe is Extended?
Elderplan may extend the standard review period if more information is needed and the extension is in your interest. You will receive written notice explaining the reason for the extension and the new expected decision date. If the extended request is ultimately approved, this is separately tracked in our annual PA metrics.
After You Apply: What Happens Next
Once a prior authorization request is submitted, here's what to expect from Elderplan's review process and how you'll receive your decision.
What Elderplan Does After Receiving Your Request
We receive your request
Once we receive your request, we begin our review. Keep a record of when you submitted it and who you spoke with, in case you need to follow up.
We review your request
Our care review team checks your request against Medicare's coverage guidelines. If your case needs a closer look, a physician on our team personally reviews it. No request is ever denied for medical necessity without a doctor's review.
We may ask for more information
If we need more medical records or clinical notes to complete our review, we'll reach out to your provider directly. We'll let you know if this happens.
You receive our decision
We send you a written decision within 7 calendar days for standard requests, or 72 hours for urgent requests. If we need more information from your provider, we'll let you know that too.
You and your provider are notified
Both you and your doctor receive written notice. If approved, the notice includes an approval reference number, the specific service covered, and the dates the approval is valid. If denied, the notice explains exactly why and how to appeal.
If Your Request is Approved
An approved prior authorization authorizes the specific service(s) listed for a defined period. You must still receive the service from an in-network provider (unless an out-of-network exception applies). An approval means Elderplan has confirmed the service is covered — your regular copays, deductibles, or coinsurance still apply as outlined in your plan benefits.
If Your Request is Denied
If Elderplan denies a prior authorization request, you will receive a written notice that includes the specific reason for the denial, the clinical criteria used to make the determination, and instructions on how to request a copy of those criteria and how to file an appeal. You have the right to appeal.
Denials & Appeals
If your prior authorization request is denied, you have the right to appeal. Elderplan provides a multi-level appeals process, and you have access to independent external review if needed.
Common Reasons for PA Denials
The submitted clinical information does not show that this service is medically necessary for your diagnosis and condition based on Medicare's coverage guidelines. Your provider can submit additional medical records or a letter of support to strengthen the request.
The requested service is either not covered by Medicare or is excluded under your specific plan's Evidence of Coverage. Review your Evidence of Coverage (EOC) — the plan document you received when you enrolled — or call Elderplan Member Services at 1-800-353-3765 [TTY: 711], 8 a.m. to 8 p.m., seven days a week to confirm your coverage.
The requested service would be provided by a doctor or facility outside our network, and your plan does not include an out-of-network coverage option for this type of service. Prior authorization is required for out-of-network services in most cases.
The request did not include enough clinical information for a determination to be made. This is addressable — your provider can supplement the submission with additional records.
The Appeals Process
Level 1 — Internal Appeal (Redetermination)
Request a reconsideration of the denial from Elderplan. You or your authorized representative must file within 60 days of receiving the denial notice. Elderplan must issue a decision within 30 days (standard) or 72 hours (expedited).
Level 2 — Independent Review Entity (IRE)
If Elderplan upholds the denial, an independent organization (not connected to Elderplan) reviews your case. CMS contracts with the IRE, which must issue a decision within 30 days (standard) or 72 hours (expedited).
Level 3 — Office of Medicare Hearings and Appeals (OMHA)
An independent federal hearing officer (Administrative Law Judge) reviews your case. Available if the dollar amount in dispute meets a minimum threshold set by Medicare.
Level 4 — Medicare Appeals Council
Review by the Medicare Appeals Council within the Department of Health and Human Services.
Level 5 — Federal District Court
If the amount in dispute meets a threshold, you may seek review in federal court.
Your Rights Regarding Prior Authorization Denials
- Receive a written denial notice with the specific reason and the clinical criteria used
- Request a free copy of the clinical criteria used in any determination
- Request an expedited appeal if your health situation requires urgent resolution
- Appoint a representative to act on your behalf throughout the appeal process
- File a grievance with Elderplan if you believe you were treated unfairly
- Contact Medicare directly: 1-800-MEDICARE (1-800-633-4227)
- File a complaint directly with Medicare at Medicare.gov
For detailed instructions on filing an appeal, visit the Exceptions, Appeals & Grievances page →
Services Requiring Prior Authorization
A complete list of service categories that require prior authorization before you receive them, grouped by plan type. Requirements vary by plan — use the filter below to see what applies to you.
HCPCS Code Lookup
This list is primarily used by doctors, nurses, and billing staff to look up specific procedure codes. If you're a member wondering whether a service needs approval, the Services Requiring Prior Authorization list is easier to use — or call Elderplan Member Services at 1-800-353-3765 [TTY: 711], 8 a.m. to 8 p.m., seven days a week and we'll check for you.
| HCPCS Code | Category | Description |
|---|
| HCPCS Code | Category | Description |
|---|
Prescription Drug Prior Authorization
Drug prior authorizations are governed by your Part D prescription drug benefit — completely separate from medical service PA. Different rules, different processes, different timelines.
How Drug Prior Authorization Works
If your prescribed medication requires prior authorization, you, your representative, or your doctor must request approval from Elderplan before filling the prescription. Without approval, Elderplan may not cover the drug.
Prior Authorization
Certain drugs require advance approval to confirm medical necessity and appropriate use. Check the PA List to see if your medication needs approval.
Quantity Limits
Some drugs have quantity limits based on manufacturer dosing guidelines. If you need more than the allowed amount, your doctor must submit supporting documentation.
Drug PA Resources
Check Your Authorization Status
Track the status of a pending prior authorization request, or view decisions on past requests using one of the methods below.
Call Member Services
The fastest way to check your status. Have your Member ID ready. If you have a reference number from a previous submission, that helps too — but we can also look up your request from your name and Member ID.
Elderplan Member Services at 1-800-353-3765 [TTY: 711], 8 a.m. to 8 p.m., seven days a week
Provider Portal
Providers can check PA status in real time through the Elderplan provider portal. Providers: submit requests and track status online 24/7.
Access Provider Portal →Via Health App (2027)
Starting in 2027, you'll be able to view your prior authorization status — including approval or denial with specific reasons — through health apps that connect to your Elderplan account.
See available apps →View PA Status Through a Health App
Elderplan supports secure data access through several trusted health apps. These apps can display your claims, visit records, and prior authorization information. Starting in 2027, the reason for any denied request will also be available through these apps.
This list is not exhaustive. Elderplan does not endorse any specific app. Always review an app's privacy policy before connecting it to your health data. Learn more about health data access →
Our 2025 Prior Authorization Results
Federal rules require health plans to publicly report prior authorization results each year. Below are Elderplan's results for Plan Year 2025. These results cover medical service prior authorizations only — prescription drug prior authorizations are reported separately under your Part D drug benefit.
Regulatory Decision Deadlines
Standard Prior Authorization
Maximum time from receipt of a complete request to a determination.
Expedited (Urgent) Review
For urgent requests where the standard timeline could jeopardize your health.
Federal Requirements
Federal rules require Medicare Advantage plans like Elderplan to publicly share prior authorization results each year. These results cover only medical service authorizations — prescription drug prior authorizations are governed separately under Part D. Our 2025 results are posted here in compliance with that requirement.
View your PA status in a health app
You can already access your prior authorization status through certain health apps that connect to your Elderplan account. See which apps are available →
Electronic submission for providers (coming 2027)
Starting January 1, 2027, your doctor's office will be able to submit prior authorization requests electronically through their health record system. Details available January 1, 2027
Your care team can see your PA information (coming 2027)
Starting January 1, 2027, your in-network doctors will be able to view your prior authorization information directly — helping coordinate your care more smoothly.
Your PA history follows you if you change plans (coming 2027)
Starting January 1, 2027, if you switch health plans, your prior authorization history will transfer automatically — so you don't have to start over.
